MEDICARE: GREAT LAKES FAMILY CHIROPRACTIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301008451	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811975717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES FAMILY CHIROPRACTIC, INC.

Provider Business Mailing Address
First Line	:	3138 BROADMOOR AVE SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49512-1845
Country	:	US
Telephone Number	:	616-241-4040
Fax Number	:	616-475-6953

Provider Business Practice Location Address
First Line	:	3138 BROADMOOR AVE SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49512-1845
Country	:	US
Telephone Number	:	616-241-4040
Fax Number	:	616-475-6953

Authorized Official
Title or Position	:	DR. OWNER
Name	:	DR. DOUGLAS GENE MCKENZIE
Credential	:	D.C.
Telephone Number	:	616-241-4040

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	08/22/2020

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Directions to “GREAT LAKES FAMILY CHIROPRACTIC, INC. ” Practice Location

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